Healthcare Provider Details

I. General information

NPI: 1710089057
Provider Name (Legal Business Name): JIM MARTIN CPT,FNP-C,MSN,AEMT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/05/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

157 CLINIC AVE SUITE 201
CARROLLTON GA
30117-4454
US

IV. Provider business mailing address

157 CLINIC AVE SUITE 201
CARROLLTON GA
30117-4454
US

V. Phone/Fax

Practice location:
  • Phone: 770-214-2800
  • Fax: 770-214-2803
Mailing address:
  • Phone: 770-214-2800
  • Fax: 770-214-2803

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberRN112921
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: